Marketing Mayhem

Reading Howard Zinn last night about the numbers of English males who volunteered for duty and were promptly slaughtered during World War I, I was struck by the idea that we tend to repeat the past, but, if there is any consolation, as bad as Viet Nam and Iraq and Afghanistan have been, they have been only pale reflections of what others have suffered through the marketing of the idea of "Patriotism" or the mass indoctrination of what you owe God and Country.

World War I was fought for the flimsiest of reasons--people are still trying to figure out how that one started, who drove it, and who benefited, but clearly, whatever got that one going, it was not to make the world safe, or to make it safe for democracy or for whatever other reasons were given by the English government, the German government or the French or the American governments.

As Slim Charles tells Avon Barksdale in The Wire,  "Don't matter who did what to who now. Fact is, we went to war. If it's a lie, then we fight on that lie, But we got to fight. That's what war is, you know."

Slim Charles is a street hood in Baltimore, He hasn't gone to school. He's been schooled on the streets. And, as if in testimony to Paul Simon's line, "When I think back on what I learned in high school, it's a wonder I can think at all."  Which is to say, if you are living your life outside the mainstream, your mind is not distorted by all the marketing and indoctrination. 

So it is the little child who can see clearly that the emperor has no clothes. He hasn't been schooled not to see the truth.

Zinn takes us through a month by month slog through WWI with the English general making some idiotic decision to send waves of soldiers across fields as Wellington once did, only to have them mowed down by modern machine guns. So 600,000 are lost in a month. Then another 500,000. Whole armies of Englishmen are mowed down. And on the home front people are told to not think they know as much as the general who is issuing these orders.

Know your place. Don't disrespect your betters.

And here we are listening to secretaries of defense, four star generals talking about "The Mission" in Iraq and "The Mission" in Afghanistan, as if there were a real mission in either place.

What is The Mission?

To deny Al Qaeda a "Safe Haven?"  What idiot would believe you can deny a group of 19 men a safe haven? Groups so small they can live in an apartment in Germany or a hotel room in Florida, and you think you can destroy them by invading a country as big as Texas, where the people don't speak your language and they can hide in mountain caves?

So, if it's a lie, then we fight on that lie.

One of my favorite series is Band of Brothers. If The Wire is a dystopia about dysfunctional institutions, then Band of Brothers is a story about an institution which actually did work, or at least an institution which bumbled into success. Certainly, you see the American army making stupid mistakes--giving parachute troops a bag to carry their equipment which they were supposed to strap to their ankles and jump out of the plane--and popping this on them after two years of training, giving them this untested bag the night before their jump into Normandy. And the bags, containing weapons and ammo simply blew away, leaving troops landing without weapons. And the night jump leaving troops miles from their targets. But, somehow, the officers and men were trained well enough to overcome obstacles and they succeeded.

As is typical of a Stephen Spielberg production, there is a heavy lard of sentimentality which nearly destroys the story.  In the episode titled, "Why we fight," the 101st airborne stumbles onto a concentration camp. This happens just after a scene where one of the soldiers has told his comrade he doesn't fight to win a war, but to simply survive and, at least, to be able to use toilet paper again and to sleep on a bed with real sheets rather than in a foxhole. This same soldier is stunned by what they find in the concentration camp. And the moral of the story, is that's what we were fighting for, to defeat a hugely evil entity--the Third Reich.

The problem is, how can you say the why you are fighting is for something you never knew existed until after you had defeated it.

You took on faith, you believed the marketing that you were fighting on the side of God. But the other side was told and believed they were fighting you because they were on the side of God. (The Germans wore belt buckles, Gott Mitt Uns.)

So it's not why you fought. You can't invent a motivation retrospectively. You fought because you wanted to for other reasons. Because you bought into the idea of heroism, of God and Country or for the adventure, or to escape boredom and a sense of meaninglessness. But you did not fight to free the victims of Nazi Germany who were buried in concentration camps you knew nothing about.

We were hoping to find weapons of mass destruction, mass graves, something in Iraq to justify our crusade, but we did not. So why did we fight there? Because we believed the line Saddam Hussein was evil. He probably was, but no more evil than a dozen other despots. Why him?

We fight on that lie.

As for Osama Bin Laden, well, I'll accept on faith he was a murderous man--or on the possibly tampered evidence of his Internet videos in which he spewed hatred toward America. He may or may not have had much to do with 9/11, but he was apparently a cheerleader, so I'm happy he's dead.

But what lies have we been sold about him?

You have to believe there are haters when you watch the evening news and see the random bombings of trains, subways, markets. There are haters out there for us to hate, hunt down and fight. But, how can we trust the people who say they know who the villains are and how to get at them?

I haven't figure out that part yet.

Karen Sibert, MD and Don't Quit This Day Job

--Bring All Your Medications in a Bag to Your Next Office Visit


Dr. Karen Sullivan Sibert wrote a lovely, politically incorrect, thoughtful, incendiary op ed in the Sunday New York Times about the effect of women in medicine who believe their first job is being a mother and their second is being a medical doctor.

Dr. Sibert writes in the long tradition of the older physician looking disapprovingly at the younger doctors who follow, who seem less committed, who seem soft, coddled and insufficiently tough and dedicated to be worthy of the world's most demanding and ennobling profession.

From Googling her, it appears Dr. Sibert is about 58 years old, graduated from Princeton in 1974 and from Baylor Medical School ten years later in 1984--so there was a gap between her college and her beginning medical school of about 6 years, during which she may have got married, had a couple of kids and got a start on raising them.

She practices in a specialty which is demanding in the sense of requiring a physical presence with the patient, after hours on call and long stretches of uninterrupted attention to a single patient.  On the other hand, Anesthesiology is one of those four specialties  of the ROAD to happiness, being high paying, relatively less demanding in time and on call--the others being Radiology, Dermatology and Ophthalmology.

Residency training programs are the most competitive for these spots, presumably because medical students now look to these coveted spots as the doorway to a happy life of prosperity without much pain.  The dermatologist does not get called in on weekends or nights, and really does not need hospital privileges and his patients do not get very sick and when they do, he hands them off to the oncologist or to someone else.  Radiologists often do not see the patient at all, dealing only with images of the patient, and so never has to give bad news or answer vexing, emotionally draining questions. He simply speaks to the referring physician and sends the patient the bill. Ophthalmologists do have to meet the patient face to face and they have some pretty delicate and sometimes nerve wracking surgeries to perform, but for some golden years, ophthalmologists gave up all those more taxing parts of their specialty and opted out of vitrectomies and cataract surgery for LASIK surgery, which was low pressure and highly compensated.

I was reminded of the National Public Radio show which reported a confrontation between the Dean of Medicine at Mount Sinai Medical School in New York city and a fourth year medical student who had been top of his class, but who chose a training program in Florida of minimal academic standing. He could have done his gastroenterology training at the finest Harvard programs and the Dean was disappointed his name was followed by a community hospital program and it made her list of graduating seniors look bad.  The student said, "If I trained at Harvard, I'd be slaving away doing research for some faculty twelve hours a day, trying to learn endoscopy and colonoscopy during the remaining six hours. In Florida, I can do my colonoscopies from 9 in the morning to three PM and be on the boat with my family by 4 PM."

Such were his values. He knew why he went to medical school and what he wanted from medicine.  He was honest enough to say so to his Dean's face.

It reminded me of my encounter with the Chief of Medicine when I was a fourth year medical student. I had just finished a fourth year elective down at New York University in the department of dermatology. I loved it. It had just enough surgery, lots of patient interaction, a wide variety of diseases and instant diagnoses.  I brought in the form for a recommendation from the Chief of Medicine for the derm program at NYU.  Cornell, my school, did not even have a department of dermatology. The Chief held up the form between finger and thumb as if it were a soiled piece of toilet paper.

"We have trained you to save lives. You did a nice job during your subinternship in Medicine. You learned how to bail out patients in sepsis, how to get a deathly ill patient through the night, alone, with confidence. And now you want to leave medicine? For this? We were going to rank you highly for a spot in our internship class. But we want to train people at this institution who are going to go out and save lives."

I slinked out of that office with my tail dragging along the floor.

Those were the days when you were either a doctor or you were ashamed of not being a doctor once you got the chance.

There was no mention of time on boats or of time with family.

But eventually, the younger doctors refused to go to Saturday morning Grand Rounds because they could not go to their kids' soccer games and they argued Grand Rounds could be held during the week. They put forth the argument that family time was a reasonable thing for doctors to demand, that the medical profession could be arranged to accommodate family life. Male doctors said this, not just female doctors.

It is true female doctors take more time off, work part time more often, but male doctors do not put in the hours or sacrifice home to profession the way they once did.

And when you make the argument about precious and limited places in medical school, well that is true if you are talking about Baylor or Columbia P&S or Duke. It is no so true of Florida State and who knows how true it is  of any of the hundred plus chiropractic schools which grant DO degrees?

And, the fact is, from my viewpoint in New Hampshire, many if not most patients get their primary care from nurse practitioners or physicians' assistants who are practicing independently of physician supervision.

What Dr. Sibert is really complaining about is the devaluation of what it means to be a physician. You work really hard to get into a school like Baylor. You take ridiculous courses (of doubtful value) like organic chemistry, calculus, physics, which are designed to cull the herd, not to select the best physicians and surgeons. And when you get that degree, you feel proud.

But then you see others, who are also called "Doctor" who do not seem to place the same value on being the best physician, the most dedicated physician they can be. They seem to look at the profession as if it were, at best a trade, something to generate profit, and not the focal point of their lives.

But then again, when I was a medical student the old dinosaurs used to disparage the interns and residents who were training me because they worked only every third night on, rather than every other. In the Days of the Giants when men were men (and their were few or no women doctors) you worked every other night, which meant you worked all the time. Your night "off" was just a recovery night to sleep and when you awoke, you were back on the ward.

Trouble with the Days of the Giants, the patients were not as sick; there was not nearly as much you could actually do for the patients and there was only a 50/50 chance of helping any patient. Now the odds are much improved; the technology has transformed medical practice--thyroid sonogram has supplanted thyroid physical exam; endoscopy has replaced hourly hematocrits;CT and PET and MRI have made autopsy confirmation of diagnosis less critical.

Things have changed.

Money has driven most of these changes;  technology has driven other changes.

But mostly, we have a dysfunctional system of selecting tomorrow's doctors and a dysfunctional system for training them. We have Deans and Chiefs who do not embody toughness and dedication. 

At a forum for parents of medical students a graduating fourth year student told his story of having been accepted to Columbia P&S and going into the Dean of Admissions saying he wanted to defer his acceptance so he could work at Goldman Sacks for a year, to get the finance bug out of his system. (And to earn some money for medical school.) The Dean agreed.

In my day, the Dean would have said, "If you are so insufficiency dedicated, we withdraw our acceptance." Medical school admission was a glittering prize. You had to prove yourself worthy of it.

That's not true at too many medical schools any more.

Patriotism on Memorial Day

The flags are out today, all along Exeter Road and High Street in Hampton, New Hampshire.
It's Memorial Day and the American Legion, which has a building right across the street from the bank, with a gun from the USS Wilimington out front and a stack of cannonballs has men wearing those American Legion hats standing around the front door.

On days like this I get a rush of images blowing by my eyes: The local Democrats beginning their meeting with the Pledge of Allegiance, the look on my high school teacher's face when we started discussing Henry David Thoreau's On Civil Disobedience, the face of a man I met who had his eye, hand and part of his foot blown off in  Viet Nam, who had nothing but dismissive contempt from the "Professional Veterans" he saw down at the Viet Nam Memorial the first and last time he went down there, the picture from Butterfield's wonderful pictorial history of the United States, showing American soldiers standing on top of piles of Filipino bodies from the Spanish American war, a war American school children never heard about when I was in school, and the photo in an article in the New York Times Book Review, of the former head of Fannie Mae, some guy name Johnson, who pocketed 100 million dollars for his part in the financial collapse which greeted President Obama upon assuming office, and the photo of Sanford Weill, who was responsible for getting a Depression era law repealed which was meant to prevent the occurrence of another Depression, but the law had stood in the way of Weill's making a profit, so he threw enough money around Congress to get it done. He made untold millions, and just to show he was a good guy, he donate $150 million to Cornell University Medical College and got the school renamed, after himself. 
    
      So all that streams by. 


      And I think about the fact this country is the only country I'm aware of which ever fought a war, and a the most costly war of all our wars, to free an underclass, to free our own slaves.  So you have to give us some credit. 


      But, as anyone who has not been in the military but who has seen The Band of Brothers or Full Metal Jacket can appreciate, the reasons men join the armed forces to go to war are seldom love of country. Each joins for his own reasons. Very few do what that professional football player did, drop a million dollar career and join the Army to go fight (and die) probably pretty much in vain, in Afghanistan.


      Thoreau said the real patriotic serves his country best not as a "wooden solider" but with his mind. The real patriot asks himself and his government why going to war is necessary and in the interests of his fellow citizens, and analyzes the answers he gets with ruthless dispassion. I did not understand what he meant by "wooden solider" in high school, but I know now. And, having lived through the Viet Nam years, I agree with him.


     As for the Pledge of Allegiance, well, all I can say is any "patriotism" which is easy is not patriotism at all. It's just all "Zeig, Heil," feel good, group hug and worse than useless.


    And as for America being the best country in the world, well, it may have become that, although the competition is not stiff. But we have a very sorry past to consider, to be informed by.  We had white American boys of the most murderous persuasion giving vent to their unwholesome passions from the Phillipines at the turn of the 20th century, to Viet Nam in the middle to Abu Gharib in Iraq, so there is very little to be proud of there.


    On the other hand, we fought a war which helped defeat Hitler, and we did fight that great war to free the slaves. And don't get miss led by later revisionism. Just read Lincoln's second inaugural address--he clearly says everyone knew, at some level, the slaves were the cause of the conflict. More succinctly, when he met Harriet Beecher Stowe, who wrote Uncle Tom's Cabin
he leaned over and shook her hand (she was just about five five tall) and he said, "So this is the little lady, who wrote the book, that started the great big war."


     

Atul Gawande: Knowing What Good Is

Atul Gawande delivered the commencement address at Harvard Medical School this year, and it was published in The New Yorker.

The Phantom would like you to know, right from the start, he is a big fan of Dr. Gawande, of Harvard Medical School and of The New Yorker (not necessarily in that order.)

But there is something disturbing about Dr. Gawande's remarks, and I'm having trouble distilling just what it is that bothers me.  The word "facile" keeps percolating up, and that's not a word I'm fond of.  But it sort of gets stuck in place, somewhere in the higher cortices, blocking synapses and I'm stuck with it.

Here's how it breaks down: First, there is the history of medical practice as depicted by Dr. Gawande, which does not fit the history I have lived through over the past decades. I think I can speak for almost the past 50 years of medical practice even though I haven't been in medicine quite that long--I have my sources.  Second, there are the claims about what ails us now (an unwillingness to work in groups and big organizations). Third, there is the solution, or set of solutions (checklists, identifying best practices, insisting on these clearly identifiable best practices and using this approach to solve the financial problems of American healthcare) and Lastly, there's the endorsement of where our new young doctors are heading, the skills they seek and the values they embrace.

History as He Sees It:
"We are at a cusp in medical generations."
                 I heard that at my own graduation nearly forty years ago and have heard it every year since. It seems medicine is forever on the cusp of something.

"When doctors could hold all the key information patients needed in their heads and manage everything required themselves."
                 He alludes to 1937, and maybe doctors could know it all then, but clearly, I did not think I had a chance to know it all, forty years ago. Even when doctors were mixing up their own medicines, I doubt they thought they knew it all. There was never a use-to-was like this, the good old days when things were simply and a doctor could know everything.  Good doctors have always been humble enough to know how little they knew.

"One needed only an ethic of hard work, a prescription pad, a secretary and a hospital willing to serve as one's workshop."
                  Dream on. Never was such a time.

What Ails Us Now:
"Two million patients pick up infections in American hospitals."
"Forty per cent of coronary disease patients and sixty percent of asthma patients receive incomplete or inappropriate care."
         I'm sure he's referring to some study or another, but ask yourself,  how would you design a study to actually figure out exactly where patients picked up their infections and whether or not patients were appropriately treated? First you'd have to know exactly when and where those infections were acquired and you'd need to be able to know really adequate coronary and pulmonary care when you saw it and you'd need really nifty metrics to figure out how often this care was delivered. 
         Just a for instance: When beta blockers were new, back in the 1970's, the worst thing you could do with them was to give them to a patient in congestive heart failure. Giving spironolactone to a patient with congestive heart failure was thought to be pissing in the wind--more potent diuretics meant good care. Aspirin was thought to be irrelevant. Today, quality of care people track beta blockers, spironolactone and aspirin as indices of good care.  So what was bad to ineffective care then is good care now. Do you really think these things will still be good care ten years from now? So how do we get so high and mighty about knowing what the right thing to do for Americans hearts really is?

"It's like no one's in charge--because one is."
            Again, teamwork and working as part of a big system is nothing new. As a medical student and an intern, forty years ago I worried I could never survive in private practice because all I knew was my part as part of the big wheel of the hospital. I realized there were dozens of people who were behind me every time I treated a GI bleeder, from the lab techs to the blood bank techs to the nurses to the guy in the ER who screened the patient.  Cooperation is nothing new in American Medicine.

"Medical performance follows a bell curve, with a wide gap between the best and worst results."
          Interesting if you could actually identify metrics for what makes for good medical performance. This reminds me (you knew this was coming) of The Wire that wonderful scene where Howard "Bunny" Colvin tells his young detective sergeant, Carver, about the destructive effects statistics have had on police work. When all you care about is how many arrests you've made, or how many pounds of heroin you've seized, you stop talking to the woman on her stoop, who might tell you who raped the girl down the block, or who shot the kid in the street. You're too busy buffing your statistics; you don't care about getting to know the woman on the stoop.


The Solutions:
"You must acquire an ability to recognize when you've succeeded and when you've failed for patients."
              He's right about that. What is more interesting is how.
"People in effective systems become interested in data. They put effort into collecting them, refining them, understanding what they say about their performance."
              Actually, I couldn't agree more. This is really Moneyball , which every doctor should read. When you just care about batting averages, you miss better metrics, like on base percentage.

"The simplest checklist...[can allow us to] eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well."
             He's written a whole book about checklists. He is a true believer. But the first sign of aging is when you find you are repeating yourself.  I really like checklists. Use them all the time. If they are good enough for airline pilots, they are good enough for me.

"The recognition that others can save you from failure no matter who they are in the hierarchy."
             This is really a cool idea. Not new, but very cool. When I was a third year medical student, I was astonished when the circulating nurse in the OR told the surgeon, who everyone was afraid of, to reglove because he had "Broken scrub." The system was in place then, as I'm sure it still is. The nurses watched the surgeons and no surgeon could pull rank when it came to breaking sterile field.

The New Young Doctors Will Save Us
"I see this in the burst of students obtaining extra degrees in fields like public health, business administration, public policy...Of some two hundred students graduating today, more than thirty five are getting such degrees, intuiting that ordinary medical training wouldn't prepare you for the world to come."

        I'd love to believe this. But another way to see it is this new crop of physicians and surgeons are not committed to medicine; they have seen the future and they realize they need a way out of medicine.  Or as one fourth year student told his Dean, "I do not want to do research. I do not want to teach in a medical school. I want to do my colonoscopies from nine in the morning to three PM and be on the boat with my family by 4 PM." 
       And this is the generation of medical students who call the ROAD to happiness Radiology, Opthalmology, Anesthesia and Dermatology--specialities which have the following characteristics :1/ High income  2/ Minimal interaction with patients 3/ Good, predictable hours.

      So Atul, I love your enthusiasm and your drive to improve medical care in America.
      But as my mother, who taught high school, once told me, when I asked her what the job of a high school  principal is,  she replied, very simply:  "He has to know what good is. And that's no small task."

Certain

"Why is it the stupid are cocksure and the Intelligent full of doubts?"


Every day, I listen to people who cleave to beliefs which fall into all sorts of disparate categories: There are beliefs which sound as if they are correct: Like the idea that the federal government is  spending more than it brings in and this means we are headed for certain disaster; there are beliefs which sound right, initially but then you said, "Wait, what?": Like the Republican/Tea party/Rush Limbaugh mantra that deficits are the fault of the Democrats and if only the Republicans controlled the Senate and the White House, we would proceed forthright to the promised land.

But then I ask, how does that heckler I heard on the radio know with such certainty that government spending, such as we are currently doing, is sending us down that slick tube to perdition and destruction? When you listen to other people who just might have some grasp of the numbers, as I did last Sunday when Paul Krugman, an economist,  said actually we are not spending at historically high levels and we might actually be better off, in the long run, spending more, creating jobs and infrastructure which are in fact an investment in the future, it makes me wonder how that heckler (who had gotten herself to a town meeting with some unfortunate Congressman) how did she know about government spending and its dire consequences?

As for the deficit, which John Boehner assures us is the fiery abyss, then why is he unwilling to tax the rich, tax the oil companies, in short, take steps to increase the government's income?

The Republicans are always comparing the economy to our household budget, always put us at the kitchen table with the bills and the pay stubs--they make it all so simple.

But when times have been tough at home, I went out and sought ways to increase my income. There was a certain amount of spending we either could not reduce or which did not seem prudent to reduce, so I earned more.

And that's what the Republicans seem to so blithely not be willing to see: Need more money? Raise taxes.  Add new taxes. Get us out of the recession, and people will have jobs, pay more taxes and then we can cut back on those individual taxes because the tax base will have expanded.

But somehow, this does not seem a possibility to John Boehner and Mitch McConnell. It does not fit into their belief system.

So there we have it:  Unshakable beliefs are the immovable object. But what do the Democrats have in the way of Irresistible force?

Clueless

Someone named Ronen Avraham, a professor at the University of Texas School of Law, wrote an Op Ed piece in the NY Times (3/28/11) about the Obama administration's plan to invoke clinical guidelines as a solution to frivolous malpractice litigation. The good professor apparently had spoken with enough people to know that the problem with clinical guidelines is they are often written by the wrong people, and sometimes by people who have ulterior motives, e.g. to promote profit for the people the authors of those guidelines are working for. The other problem with the guidelines is they are too often written by people with the time to write them, faculty members at medical schools, who, perhaps surprisingly, are not the sharpest blades in the drawer.




I recently regaled a conference at my own hospital by simply reading from the clinical guidelines for the in patient management of diabetics which said, among other brilliant things, if the patient you are treating is terminal, i.e., if he is expected to die within a short time, then controlling his blood sugar, lowering it to normal ranges by the use of intravenous insulin may not be required, or at least it may not be as important as this practice would be for people who are expected to survive their hospitalization. Which is to say, if you are dying of widely met static lung cancer, if you have it growing in your brain, getting your blood sugar into normal range may not be your highest priority.



Ya think?



So who should be writing guidelines? And, more basic, is it really possible or wise to attempt to write guidelines at all? Is medical practice not in a constant state of flux, adjustment and re examination and is it not so complex that writing a single manual is impossible? Is this not what we go to medical school, residency training, specialty conferences to learn? It's like that old saw where the author is asked by the radio show host, "So what's your novel about, in a sentence?" and he replies, "If I could tell you that, I wouldn't have had to write the novel."





Some things are complex enough to defy simple dictums.





Then there is the case of "Medical Economics." The Obama people have their hearts in the right place: They want to provide health care for all, and they want to do all this at the lowest possible cost. But, understandably, they don't know where the hemorrhaging is. If you don't know the anatomy or the physiology, you are not going to find the bleeding point.





Not that the Republicans have any idea. What they have is fantasy. And fantasy is, at least, coherent--it makes a good story: Just let the market drive down costs. Get the malpractice lawyers out of the picture, driving up costs as they do. Stop all the regulation. Private enterprise will save all. Republicans love living in denial. They will cleave to these fantasies with ferocity, because they want to believe all this.





The Obama people, Peter Orszag in particular, have their own fantasies. They wanted to believe economists could tell them where the savings can come from. And they wanted to believe Atul Gawande had done a bone fide piece of medical economic analysis in Texas, showing the way as he described one Texas town where the billings to Medicare were very high versus another where they were close to the median as if these two towns held some sort of key. In the expensive town, it was all about greedy doctors, bilking the system by doing unnecessary tests.

So that's the answer! Search out those bogus, unnecessary tests!





Nice fantasy.





The real problems, of course, are much more pervasive and more difficult to fix because so many people are making so much money and they vote and they spend that money to hire elected officials.





A colonoscopy makes a local hospital $3400 and that's not even including the doctor's fee. This is a test which could be done by a technician for, reasonably, taking into account the overhead for equipment, cleaning equipment and staffing support, say $250 a pop and you could screen a lot more patients at far less cost. But colonoscopies are the cash cow of the gastroenterologist: he learns the procedure in a few months, masters it in a year and then supports his family and his boat payments doing this procedure which can be scheduled and is never an emergency, and he can be on his boat by 4 PM. You think the GI docs are going to give up that without a fight?





Similarly, you could replace 95% of dermatologists with technicians who could do excisions and biopsies at a small fraction of the cost people with MD's charge. This is another group which works 9 to 5 and profits are so enormous dermatology residency training programs are now the most competitive residencies out of medical school. Everyone wants that life and income.





Well, not everyone. Just the people who had really high SAT scores in high school, really great grades in college and who learned how to play the game to their own advantage. These are not people who dreamed of being heroes, saving lives in the middle of the night, leaving their warm beds in the middle of the night and driving into the hospital where a distraught family awaits, holding the hand of their stricken mother.





No, the dream of some medical students is a big house, nice cars and maybe a boat.





Truth be told, that hero dream is not much to be found in medicine anywhere. Just look at the TV programs now if you want to see the screen writers' fantasies about the possibilities of a medical career.





And with the advent of shift work in the hospital, with hospital doctors now just employees and with doctors in the community no longer self employed in private practice, medicine is becoming or has become not an ennobling profession, but just a job.





Medical practice has been deconstructed into its parts: Much of it is now being done by nurse practitioners, "procedurealists" , laceration technicians, physicians' assistants and other people who never went to medical school but took a short cut to the white coat and the stethoscope.





Not all of this is bad, but none of it saved money to the total system and the important part of medicine, which never paid well, is now often not done at all. That's the part where you listen to a patient's story, told in a fractured way by a person who does not have a clue what may be relevant and you tease out a coherent whole which tells you what test to order and to which specialist or for what procedure to send the patient.





One thing which looks pretty clear is the economists who do medical economics at Princeton, or MIT or Harvard or Chicago have no idea which rock to look under. Their approach, their tools are simply incapable of finding the truth, or any meaningful answers. They simply do not know how to do ward rounds and to gather the right information or to organize it into a meaningful analysis.

 

Survivor Resentment

A long article in the New York Times today about a psychiatrist who had to give up the practice of psychoanalyst and shift to the practice of pushing psychotropic medications. He went from seeing ten patients a day to forty and he feels unfulfilled, says he hardly knows his patients, can hardly remember their names now. Years ago, he knew them in some ways better than their own spouses and lovers. Now, he is "efficient."

Of course, no law required him to give up the aspect of his practice which he found most spiritually rewarding: It was financial forces. Talk therapy was devalued, in part because a psychiatric social worker with a masters degree two years out of college could do what he was doing with talk therapy, at least as far as the insurance companies are concerned. He could have studied with Sigmund Freud hisownself, undergone  ten years of psychotherapy himself, written his PhD thesis at Harvard, after two years as a Rhodes Scholar at Oxford and authored the standard textbook of psychotherapy--none of those indicators of quality would matter to the insurance companies, or, for that matter to the American Board of Psychiatry which makes its living "certifying" psychiatrists and psychoanalysts.

So that is one of the many effects of a commercial system of medical care: Quality is that thing which shines with a light not perceptible by computers, bean counters or  vice presidents of corporate America.  Price is the thing.

Not that I or many of those who traveled with me through medical school, internship, residency and fellowship training have much sympathy for those who opted out of what we considered real medicine for the pseudo science of psychiatry.  We considered those people, who went into psychiatry after medical school the worst mistakes the medical school had made. Gave away the glittering prize of a place in the medical school class to someone who realized, somewhere along the four years, that he (or she) had made a big mistake and he didn't want to do medicine after all. That place could have been given to an orthopedic surgeon, a heart surgeon, a neurosurgeon, a pediatrician, a cardiologist, endocrinologist, rheumatologist, to, in short, a real doctor.

And it was not a little galling to see psychiatrists earning tons of money so easily, while people who went into the aforementioned specialties struggled. The psychiatrist in private practice was burdened with almost no overhead. Typically, they could rent a one or two room office, and they may not even need the expense of a secretary--an answering machine could do. They often admitted no patients to hospitals, did not work weekends and took no real on call at night. They had it easy. So every dollar they charged the patient was virtually all profit. For the other specialists, overhead ate up at least half of the gross income.

Which is not say psychiatrists are unnecessary or that psychiatry is not an important part of medicine dealing with important diseases.

My medical school class confronted the department of psychiatry at our medical school and refused to do the psychiatry rotation. We had read a book by Thomas Szaz, The Myth Of Mental Illness. So we were very well informed and we knew mental illness was just a convenient way of putting away inconvenient or obstreperous people. 

Astonishing, the chairman of the department at our very conservative and very upper crust medical school on the chic Upper East Side of Manhattan, listened quietly to all these rants from the students and, once they had finished, he said, with a sly smile. "Okay, I'll make you a deal. You have an eight week rotation of psychiatry scheduled for your third year. Just go to the psychiatric wards and observe for two weeks. Then come back here and we'll all meet again. If you still think, after two weeks of observing the patients on these wards we have simply made up a disease, that mental illness is just a myth, then you can have the next six weeks off, with my blessing. Go to Aruba, wherever. You'll get full credit for having completed all we expect of you in the department of psychiatry."

Of course, after three days of watching people with real big time depression, of talking with patients who afflicted by what was then called "manic/depressive illness" (now bipolar) or interviewing patients with schizophrenia who were hearing voices, not one of the ninety students in our class took the Aruba option. 

We were all humbled. No second meeting was necessary. We simply went back to the wards and watched and learned and got even more humble, seeing what those diseases were like, what they did to people, and how difficult the job of those psychiatrists really was.

Not that we were ready to embrace psychiatrists unreservedly. When we were in housestaff training, psychiatrists typically were not stand up guys: We had a patient staring out a ninth floor window at the end of the ward hallway, looking longingly at the sidewalk below, with a nurse and a medical student right there with her to prevent her from leaping out, and the psychiatric residents refused to come to the ward and do a consult.

That, in fact, was the trouble with The House of God a widely read novel about a medical internship at the Beth Israel Hospital in Boston.  After describing in detail the dehumanizing aspects of medical internship, that process by which caring human beings are transformed into dispassionate human beings who are capable of standing fast and not flinching when people who they like are going rapidly down the tubes, each of the real, sensitive, human beings in The House of God, opts out for psychiatry, as if that were the only consconable option for a real, sensitive human being. It was as if every member of Easy Company in Band of Brothers had deserted or simply refused to fight any more and been shipped back to England. None of them would have then liberated a concentration camp. But I digress.

And there are psychiatrists and psychiatrists.

One of the best psychiatrists I ever saw was that woman who "treated" Tony Soprano. That fictional show illuminated for me something I never saw in medical school--the possibility of a really insightful human being helping another human being to take steps toward a more meaningful and livable life.

Among real psychiatrists, my prize goes to the psychiatrist who had the unfortunate duty of having to spend an hour with six medical residents after we had been up all night on call with desperately ill patients on the intensive care units, the cancer wards. We had to spend that hour because the American Board of Internal Medicine required we have a certain number of hours of "psychiatric training."  Like virtually everything else about the Board, we considered this a stupid politically correct thing with no real value to insuring quality of medical training.

Oddly, though, in this one case, it did not work out that way.

The psychiatrist came in a little late, wearing a splendid tweed jacket and a spotless silk tie, freshly pressed shirt and there we sat, blood spattered, urine stained, smears of feces, vomit and dirt of unknown origins despoiling our white tunics and uniform slacks. Some of us fiddled with reflex hammers, others snapped their rubber tourniquets idly, and all of us looked unhappy about having to spend an our with this rear eschelon shrink when what we were aching to do was to go home to shower, to bed, to crash for an hour before we had to be back on the wards.

He looked around and asked what rotations we were on and we told him, one by one: intensive care unit,  Emergency Room, cardiac care unit, oncology (cancer) ward.  And he asked, idly, innocently, "See anybody die last night?" Actually, we all had, each and every one of us.

"What," he asked calmly, "Would it mean to you to learn you were going to die today? I mean, once you got past the disbelief, the anger, the rest of all that. What would it mean to you?"

And that's when it got really interesting. That's when the three guys, guys I thought I knew, who had kids, each one said, "It would mean I'd never get to see my kids grow up."

I knew these guys had kids, of course, But I almost never saw the kids. Sometimes, in a playground near the housestaff housing building, I'd see kids but I never really connected any of these kids with my friends, these band of brothers who I knew at the hospital. They couldn't have seen much of their kids, given our hours. I suppose, when they got home they could look at their kids sleeping.

Those, who like me, were not even married and were more concerned with who the next young lovely to warm our beds might be, we all said something to the effect that life had not really yet begun. We had been in school and training for something our whole lives. If we died today, we'd have missed actually having really lived.

So we did get something out of that hour, no thanks to the Board. We just happened to have lucked into a psychiatrist who knew where we had been.

I often wonder what my buddies would say if we were reassembled, about all the nurse practitioners doing primary care medicine who never had to go through what we went through on those wards, about all the "Physicians' Assistants" who see primary care patients, assist in surgery who never had to suffer through organic chemistry, physics, calculus and comparative anatomy--all those ridiculous courses which helped not one iota in learning anything which really mattered in medical school, but we had to do well enough to survive the elimination derby just to get to medical school, just to have the chance to claim a place in medical school so we could then compete for a place in a residency and then a fellowship program where we could stay up all night for years.

What would it mean to you to be told, well now a days, you don't have to do that to practice medicine or surgery?

I've thought about that a lot.

For now at least, I've come to the place where I'm saying, I didn't need to go through all that. And it was pretty awful at times. But in the end, I was lucky to have had the experience. It really was an honor and a privilege, in an odd sort of way.  I mean, nobody would say he's grateful to have had the experience of an artillery bombardment. But once he has, well, it makes him appreciate life just that much more.